Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitstrifluridine 1 GC MOZIRGAN 3 MOBETA-BLOCKERSbetaxolol hcl 1 GC MOBETOPTIC-S 2 MOcarteolol hcl 1 GC MOISTALOL 2 MOlevobunolol hcl ophthalmic soln 1 GC MO0.5%metipranolol 1 GC MOtimolol maleate 1 GC MOtimolol maleate ophthalmic gel 1 GC MOformingTIMOPTIC OCUDOSE 2 MODIRECT ACTING MIOTICSPILOPINE HS 2 MOMISCELLANEOUS OPHTHALMOLOGICSALOCRIL 3 MOazelastine hcl 1 GC MOBEPREVE 2 MOcromolyn sodium ophthalmic soln 1 GC MOCYSTARAN 4 MOepinastine hcl 1 GC MOLACRISERT 2 MOLASTACAFT 2 MOPATADAY 2 MOPATANOL 2 MORESTASIS 2 MONON-STEROIDAL ANTIINFLAMMATORYAGENTSACUVAIL 2 MOBROMDAY 2 MObromfenac 1 GC MOdiclofenac sodium 1 GC MOflurbiprofen sodium 1 GC MOILEVRO 2 MOketorolac tromethamine1 GC MOophthalmic solnNEVANAC 2 MOPROLENSA 2 MOORAL DRUGS FOR GLAUCOMADrugNameDrugTierRequirements/Limitsacetazolamide 1 GC MOacetazolamide er 1 GC MOacetazolamide sodium 1 GCmethazolamide 1 GC MOOTHER GLAUCOMA DRUGSAZOPT 2 MOCOMBIGAN 2 MOdorzolamide hcl 1 GC MOdorzolamide hcl/timolol maleate 1 GC MOlatanoprost 1 GC MOLUMIGAN 2 MOSIMBRINZA 3 MOTRAVATAN Z 2 MOtravoprost 1 GC MOSTEROID-ANTIBIOTIC COMBINATIONSneomycin/polymyxin/bacitracin/h 1 GC MOydrocortisoneneomycin/polymyxin/dexamethaso 1 GC MOne1 GC MOneomycin/polymyxin/hydrocortisone ophthalmic suspTOBRADEX OINT 2 MOTOBRADEX ST 2 MOtobramycin/dexamethasone 1 GC MOZYLET 2 MOSTEROID-SULFONAMIDECOMBINATIONSBLEPHAMIDE 3 MOBLEPHAMIDE S.O.P. 3 MOsulfacetamide1 GC MOsodium/prednisolone sodiumphosphateSTEROIDSALREX 2 MOdexamethasone sodium phosphate 1 GC MOophthalmic solnDUREZOL 2 MOFML 2 MOFML FORTE 2 MOLOTEMAX 2 MOprednisolone acetate 1 GC MO36